personally-created-cognitive-artifacts as external representations of distribut

90 Pages·2017·3.76 MB·English

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UT SBMI Dissertations (Open Access) School of Biomedical Informatics
Spring 4-24-2009
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Sharon McLane
The University of Texas Health Science Center School of Health Information Sciences at Houston,
Houston, Texas
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Part of the Medicine and Health Sciences Commons
RReeccoommmmeennddeedd CCiittaattiioonn
McLane, Sharon, "UNDERSTANDING NURSE CREATED COGNITIVE ARTIFACTS: PERSONALLY-CREATED-
COGNITIVE-ARTIFACTS AS EXTERNAL REPRESENTATIONS OF DISTRIBUTED COGNITION" (2009). UT
SBMI Dissertations (Open Access). 20.
https://digitalcommons.library.tmc.edu/uthshis_dissertations/20
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Dissertation

Understanding Nurse Created Cognitive Artifacts:
Personally-Created-Cognitive-Artifacts
as External Representations of
Distributed Cognition

By

Sharon McLane, MS, MBA, RN-BC

April 24, 2009

APROVED:

_____________________________
James P. Turley, Ph.D., RN

_____________________________
Joan Engebretson, Dr.PH., RN

_____________________________
Geri L. Wood, Ph.D., RN, FAAN

_____________________________
Jiajie Zhang, Ph.D.

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Understanding Nurse Created Cognitive Artifacts:
Personally-Created-Cognitive-Artifacts as External
Representations of Distributed Cognition

A
Dissertation

Presented to the Faculty of
The University of Texas
School of Health Information Sciences
at Houston
in Partial Fulfillment
of the Requirements

for the Degree of

Doctor of Philosophy

by

Sharon McLane, MS, MBA, RN-BC

Committee Members:
James P. Turley, Ph.D., RN, Chair1
Joan Engebretson, Dr.PH., RN2
Geri L. Wood, Ph.D., RN, FAAN2,3
Jiajie Zhang, Ph.D.1

1The University of Texas School of Health Information Sciences at Houston
2The University of Texas School of Nursing at Houston
3UT M.D. Anderson Cancer Center, Houston
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Copyright by
Sharon McLane
2009
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Dedication

To my daughter and son-in-law,
Michelle and Steve,
a wonderful couple and loving parents of
my beautiful granddaughters,
Sabrina and Tessa,
born during this project and the light of my life.

To my fellow classmates, whose support, advice, and guidance
have been instrumental to achieving this goal;
I am very grateful for your help.

To the nurses
who participated in my research
and expressed enthusiasm,
support, and excitement for this research project.

To two individuals who created several break through insights,
and supported and encouraged me
through and over the truly rough moments of this journey:
Dr. James P. Turley
Dr. Adol Esquivel

Thank you all for your faith, patience, and perseverance.
Page 4 of 89
TABLE OF CONTENTS

Introduction …………………………………………………………………………………………………………….. Page 4

Manuscript 1: “Conceptual Analysis: Externalizing Nursing Knowledge” ………….….. Page 12

Manuscript 2: “Research Methods: Exploring Cognitive Work” …………………..…….….. Page 42

Manuscript 3: “Making the Cognitive Work of Registered Nurses Visible”….……..….. Page 59

Project Summary ……………………………………………………………………………………………………. Page 84
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INTRODUCTION
Knowledge workers assimilate complex arrays of data to support the cognitive work of their
profession. Registered nurses (RN) are knowledge workers who are dependent upon a complex
array of clinical information to inform patient care decisions. The RN is continually evaluating the
clinical signs and symptoms of the patient in the context of diagnostic and therapeutic
interventions, and this data needs to be immediately accessible to support the nurse’s cognitive
processes. The practice environment of the nurse is dynamic, interruption-driven, incorporating
multiple priorities, and the requisite data is distributed among various repositories and artifacts
in that are placed in a variety of locations. A comprehensive summary of each patient’s clinical
data is not available to the nurse assigned to care for that patient. To bridge the gap between
reality and clinical need, nurses prepare a clinical summary, or cognitive artifact, each of the
patients in their care on a daily basis. This cognitive artifact is prepared for use by the nurse
caring for the patient and contains demographic, assessment, symptom, therapeutic
intervention, medication, and related data to aid the nurse in care delivery. This personally
created cognitive artifact has been named the PCCAT.
Although the PCCAT is important to the nurse, it is not without risks to patient safety.
The data recorded on the PCCAT is transcribed from other sources and is at risk for
transcription error. Data may also be inadvertently omitted, duplicated, or recorded on the wrong
patient. The data recorded early in the day becomes less current as new data is made available
in the source system. The nurse may be delayed in accessing source systems, possibly
delaying therapeutic interventions or making care decisions with outdated information.
The above information prompted this study to determine the criteria and requirements
necessary to create an information technology solution to the PCCAT, offering the nurse the
benefits of the PCCAT while minimizing or eliminating the risks. A technology solution could
also save the nurse time spent each day to prepare the PCCAT. Prior to embarking on the
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development of a technology solution, a deeper understanding of the relationship between the
nurse and the PCCAT was necessary. The data the nurse recorded and added to the PCCAT
needed to be identified and defined. We also needed to understand the heuristics the nurse
used to select the data that was recorded. While we believed that the PCCAT supported the
cognitive work of the nurse, such as working memory and other cognitive activity, the context
and nature of the cognitive support needed to be identified and explored.
Portions of the program of research are described in the three manuscripts presented as
a PhD dissertation about the study of the knowledge representations and structures embodied
by the PCCAT. The research was a multi-method, qualitative, triangulated study conducted on
three inpatient units at a comprehensive cancer center located in southern United States. Site
selection was convenience, and the participating units were a nonrandom convenience
selection. Clinical nurses who worked on the study units and who spent a minimum of 50% of
their worked time in direct patient care were eligible to participate.
The research program began with a review of the literature to understand what has been
learned about personal cognitive artifacts. We found that studies of personal cognitive artifacts
such as the PCCAT have not been reported. Some work has been reported related to the shift
report nurses share when the departing nurse provides a clinical update to the arriving nurse.
These reports do not report if or how the information exchanged, or any written documentation
shared during the report, influenced the nurse after the report was completed. Research related
to other cognitive artifacts has been reported. A study of cognitive artifacts in an operating room
(OR) setting enabled researchers to understand the role of artifacts in supporting the technical,
organizational, and workflow demands of the OR, and assisted in the recognition of gaps in an
already existing information system. Researchers concluded that in-depth study of cognitive
artifacts in the OR is a prerequisite to understanding this technical setting, the problems the
artifact is intended to address, the hazards and risks present in the environment, the ways in
which cognitive artifacts support distributed cognition, and the dimensions and complexity of the
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elements of distributed cognition in the OR environment (Nemeth, Cook, O'Connor, & Klock,
2004).
This research was based upon the assumption that the PCCAT is an instance of a
cognitive artifact. An early step in the program was to establish that the PCCAT is a cognitive
artifact through a concept analysis using the process established by Walker and Avant (Walker
& Avant, 2005), and is the subject of the first manuscript, “Conceptual Analysis: Externalizing
Nursing Knowledge”. We discovered that a concept analysis of cognitive artifacts had not been
published, so we amended the plan and converted our concept analysis into a dual process.
The purpose of the concept analysis was to clearly define the attributes and limitations of
cognitive artifacts, and their antecedents, consequences, and external referents. Once the
characteristics of the concept entitled ‘cognitive artifact’ had been established, the same
concept analysis process was employed with the PCCAT. Finally, the attributes, limitations,
antecedents, consequences, and external referents of the PCCAT were compared to those of
the cognitive artifact. The process firmly established the PCCAT as an example of cognitive
artifacts. This process placed PCCATs in the concept class of cognitive artifacts and allowing us
to determine if other concepts are the same as the cognitive artifact, or only similar to but
differing in a least one significant way.
The concept analysis, establishing PCCATs as an instance of a cognitive artifact,
enables assignment of the seven attributes of a cognitive artifact to the PCCAT, as established
by Zhang and Patel (2006). The seven attributes are 1) reduction of user memory, 2) guiding
recognition and understanding inferences to support rapid data assimilation, 3) augmenting user
knowledge and internal representations,4) supporting user perceptions and cognition without
requiring conscious effort of the user, 5) promoting more efficient and effective user action, 6)
minimizing abstraction and support effective decision making, and 7) channeling decision
making by maximizing accuracy and minimizing user effort. We also established that the
PCCAT has an additional attribute not shared with cognitive artifacts, namely that the clinical
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data record and display of the PCCAT is prepared for the personal use of a single clinician.
The second manuscript is a methods paper entitled “Research Methods: Exploring
Cognitive Work”. The manuscript describes the multi-method, qualitative, triangulated
methodology employed to study a knowledge representation and knowledge structure used by
clinical practitioners. The knowledge representation (PCCAT) was analyzed for domain content,
categorized, and coded, using document review as the method. We studied the interaction
between external knowledge representations and internal knowledge representation using
shadowing techniques. Internal knowledge representation was further explored through the use
of interviews and a clinical scenario. Data analysis was concurrent ad iterative. Each phase of
data collection informed understanding and insight of past phases, and informed and guided
subsequent phases.
The multi-method design allowed us to experience and explore issues that may have
been missed in a study with a less complex design. Shadowing disclosed the scope of
distributed cognition in the clinical environment and added important context to the domain
content identified during document analysis. Shadowing also revealed the how and when the
subjects accessed external knowledge representations and transcribed information to the
PCCAT, information that could not be identified during document review and may not have
surfaced during subject interviews. Subject interviews created a window to the meaning and
value of the PCCAT for the nurse, and enabled the nurse to share personal perceptions.
Collectively, the multi-method design allowed us to peal the layers of meaning and use
surrounding the document known as the PCCAT.
The third manuscript, “Making the Cognitive Work of Registered Nurses Visible”
describes data analysis, insights, and conclusions. The analysis of the multi-method design
enabled us to 1) prepare a taxonomy of the PCCAT knowledge representation and knowledge
structure, 2) develop insight regarding the scope of distributed cognition present in the clinical
environment and the barriers it presents to comprehensive summaries of patient condition, 3)
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